"Cold feet": A qualitative study of medical students who seriously considered emergency medicine but chose another specialty.

Introduction: Emergency medicine (EM) has historically been among the most competitive specialties in the United States. However, in 2022 and 2023, 219 of 2921 and 554 of 3010 respective National Resident Matching Program positions were initially unfilled. Medical students' selection of a medical specialty is a complex process. To better understand recent trends in the EM residency match, this qualitative study explored through one-on-one interviews the rationale of senior medical students who seriously considered EM but ultimately pursued another specialty. Methods: A convenience sample of senior medical students from across the United States was recruited via multiple mechanisms after the 2023 match. Participant characteristics were collected via an online survey. Qualitative data were generated through a series of one-on-one semistructured interviews and thematic analysis of the data was performed using a constant comparative approach. Results: Sixteen senior medical students from 12 different institutions participated in the study. Thematic saturation was reached after 12 interviews but data from all 16 interviews were included for qualitative analyses. Five major themes emerged as important in students' consideration but ultimate rejection of EM as a career: (1) innate features of EM attracted or dissuaded students, (2) widespread awareness of a recent workforce report, (3) burnout in EM, (4) their perception of EM's standing in the health care landscape, and (5) early EM experience and exposure. Conclusions: This qualitative study identified five major themes in the career decisions of senior medical students who seriously considered EM but chose another specialty. These findings may help inform the perceptions of students and guide future EM recruitment efforts.

A Multilevel Model for Evaluating Interprofessional Learning.

Medical schools should engage in best practices for evaluating preclinical interprofessional collaborative programs. This innovation models a multilevel program evaluation of Interprofessional Clinical Experience (ICE), a required course for all first-year medical students. Data from student course evaluations and preceptor surveys determined that the course was effective at teaching interprofessional practices. Competency assessments showed nearly all students achieved the expected level. On the Readiness for Interprofessional Learning Scale, students increased their self-reported attitudes around interprofessional practices. Improvements to the ICE course will continue based on student and preceptor feedback from this multilevel program evaluation.

Increasing Education Research Productivity: A Network Analysis.

INTRODUCTION: Forming effective networks is important for personal productivity and career development. Although critical for success, these networks are not well understood. The objective of this study was to usze a social network analysis tool to demonstrate the growth of institutional publication networks for education researchers and show how a single institution has expanded its publication network over time. METHODS: Publications from a single institution's medical education research group (MERG) were pulled since its inception in 2010 to 2019 using Web of Science to collect publication information. Using VOSViewer software, we formed and plotted a network sociogram comparing the first five years to the most recent 4.25 years to compare the institutions of authors from peer reviewed manuscripts published by this group. RESULTS: We found 104 peer-reviewed research articles, editorials, abstracts, and reviews for the MERG authors between 2010 and 2019 involving 134 unique institutions. During 2010-2014, there were 26 publications involving 56 institutions. From 2015-2019, there were 78 publications involving 116 unique institutions. CONCLUSION: This brief report correlates successful research productivity in medical education with the presence of increased inter-institutional collaborations as demonstrated by network sociograms. Programs to intentionally expand collaborative networks may prove to be an important element of facilitating successful careers in medical education scholarship.

Tracking Student Mistreatment Data to Improve the Emergency Medicine Clerkship Learning Environment.

INTRODUCTION: Medical student mistreatment is a prevalent and significant challenge for medical schools across the country, associated with negative emotional and professional consequences for students. The Association of American Medical Colleges and Liaison Committee on Medical Education have increasingly emphasized the issue of mistreatment in recent years, and medical schools are tasked with creating a positive learning climate. METHODS: The authors describe the efforts of an emergency department (ED) to improve its clerkship learning environment, using a multifaceted approach for collecting mistreatment data and relaying them to educators and clerkship leadership. Data are gathered through end-of-rotation evaluations, teaching evaluations, and an online reporting system available to medical students. Mistreatment data are then relayed to the ED during semi-annual meetings between clerkship leadership and medical school assistant deans, and through annual mistreatment reports provided to department chairs. RESULTS: Over a two-year period, students submitted a total of 56 narrative comments related to mistreatment or unprofessional behavior during their emergency medicine (EM) clerkship. Of these comments, 12 were submitted in 2015-16 and 44 were submitted in 2016-17. The most frequently observed themes were students feeling ignored or marginalized by faculty (14 comments); students being prevented from speaking or working with patients and/or attending faculty (11 comments); and students being treated in an unprofessional manner by staff (other than faculty, 8 comments). CONCLUSION: This article details an ED's efforts to improve its EM clerkship learning environment by tracking mistreatment data and intentionally communicating the results to educators and clerkship leadership. Continued mistreatment data collection and faculty development will be necessary for these efforts to have a measurable effect on the learning environment.

The National Clinical Assessment Tool for Medical Students in the Emergency Department (NCAT-EM).

INTRODUCTION: Clinical assessment of medical students in emergency medicine (EM) clerkships is a highly variable process that presents unique challenges and opportunities. Currently, clerkship directors use institution-specific tools with unproven validity and reliability that may or may not address competencies valued most highly in the EM setting. Standardization of assessment practices and development of a common, valid, specialty-specific tool would benefit EM educators and students. METHODS: A two-day national consensus conference was held in March 2016 in the Clerkship Directors in Emergency Medicine (CDEM) track at the Council of Residency Directors in Emergency Medicine (CORD) Academic Assembly in Nashville, TN. The goal of this conference was to standardize assessment practices and to create a national clinical assessment tool for use in EM clerkships across the country. Conference leaders synthesized the literature, articulated major themes and questions pertinent to clinical assessment of students in EM, clarified the issues, and outlined the consensus-building process prior to consensus-building activities. RESULTS: The first day of the conference was dedicated to developing consensus on these key themes in clinical assessment. The second day of the conference was dedicated to discussing and voting on proposed domains to be included in the national clinical assessment tool. A modified Delphi process was initiated after the conference to reconcile questions and items that did not reach an a priori level of consensus. CONCLUSION: The final tool, the National Clinical Assessment Tool for Medical Students in Emergency Medicine (NCAT-EM) is presented here.

Tit-For-Tat Strategy for Increasing Medical Student Evaluation Response Rates.

INTRODUCATION: It is essential for faculty to receive feedback on their teaching for the purpose of improvement as well as promotion. It can be challenging to motivate students to provide feedback to preceptors and fill out evaluation forms when not a clerkship requirement. Furthermore, there is concern that making the evaluations a requirement can compromise the quality of the feedback. The objective of this study was to identify an increase in the number of faculty and resident evaluations completed by students rotating through their Emergency Medicine clerkship following the implementation of a tit-for-tat incentive strategy. METHOD: Prior to the implementation of Tit-for-Tat, students rotating through their emergency medicine clerkship were asked to fill out evaluations of residents and faculty members with whom they worked. These were encouraged but voluntary. Beginning in the 2014-2015 academic year, a tit-for-tat strategy was employed whereby students had to complete a resident or faculty evaluation in order to view the student assessment completed by that resident or faculty preceptor. RESULTS: Students submitted 1101 evaluations in the control, with a mean of 3.60 evaluations completed per student and 3.77 evaluations received per preceptor. Following the implementation of tit-for-tat, students submitted 2736 evaluations, with a mean of 8.19 evaluations completed per student and 7.52 evaluations received per preceptor. Both the increase in evaluations completed per student and evaluations received per preceptor were statistically significant with p-value <0.001. CONCLUSION: The tit-for-tat strategy significantly increased the number of evaluations submitted by students rotating through their emergency medicine clerkship. This has served as an effective tool to increase the overall number of evaluations completed, the number of evaluations each instructor received on average and the proportion of students that completed evaluations. Further work could be done to attempt to better assess the quality of the feedback from these evaluations.

Anything but Shadowing! Early Clinical Reasoning in Emergency Department Improves Clinical Skills.

INTRODUCTION: Transitioning from the pre-clinical environment to clerkships poses a challenge to students and educators alike. Students along with faculty developed the Clinical Reasoning Elective (CRE) to provide pre-clinical students exposure to patients in the emergency department and the opportunity to build illness scripts and practice clinical skills with longitudinal mentorship in a low-stakes environment before entering clerkships. It is a voluntary program. Each year, the CRE has received overwhelming positive feedback from students. The objective of this study is to determine if the CRE improved students' clinical skills and reported comfort in their skills. METHODS: We examined the relationships between students' self-reported participation in the CRE and their individual scores on a comprehensive clinical assessment (CCA) at the end of the pre-clerkship period. A total of 178 students took the CCA exam in 2016. Of these, 113 participated in the CRE and 65 did not. Seven students who participated in CRE did not complete the exit survey and were omitted from analysis. We performed regression analysis and dichotomous (participants/nonparticipants) comparisons of means with t-tests. Survey of student reactions was collected. RESULTS: Participants completed an average of 10 sessions over the course of the program (range=1-20). Involvement in the CRE was associated with significantly increased scores on Abdominal History; Pulmonary Physical Exam; Overall History-Taking; Overall Communication; and Overall Physical Exam (p<0.05). Nearly all students (97%) reported that the program offered opportunities to enhance clinical skills, increased their comfort with patients, and better prepared them for their clinical years. CONCLUSION: There were measurable improvements in clinical skills performance for students who participated in CRE. As many schools seek to incorporate early clinical exposure to their curricula, this program provides a successful framework to provide meaningful clinical exposure to real patients that also shows objective benefits to students' clinical skills.

Medical Students' Use of Different Coping Strategies and Relationship With Academic Performance in Preclinical and Clinical Years.

Phenomenon: Medical students' coping abilities are important for academic success and emotional health. The authors explored differences in students' use of active, problem-solving strategies and emotional, inwardly directed approaches; the change in coping strategies used during medical school; and coping strategy impact on performance. APPROACH: One hundred eighty-three students completed the Ways of Coping Scale at matriculation and end of the 2nd and 3rd years. Frequency of each of 8 ways of coping, changes in coping strategy use over time, and relationship of coping method with preclinical and clinical scores were calculated. FINDINGS: Students varied widely in use of coping mechanisms. Over time, students shifted to using emotional strategies more frequently while decreasing their use of active strategies. Coping strategies were unrelated to preclinical academic performance (R2 = .09, adjusted R2 = .04, ns) but were related to clinical performance (R2 = .23, adjusted R2 = .18, p < .0001), with active coping associated with higher performance and emotional methods associated with lower performance. Insights: Students decreased use of active coping strategies and increased use of emotional coping strategies over time, but emotional strategies were associated with poorer clinical academic performance. These shifts in coping methods may be detrimental to student performance and learning. Improving students' ability to cope should be an educational priority.

Understanding the Struggles to Be a Medical Provider: View Through Medical Student Essays.

BACKGROUND: The clinical learning environment helps to shape the professional identity of medical students. This process begins from existing personal identity and is influenced by various factors, including clinical experiences and clinical learning environment. OBJECTIVE: The purpose of this study was to examine medical students' reflections as a way to identify and better characterize the modern struggles that medical students face, in order to inform the development of professional identity. METHODS: Students rotating in their emergency medicine clerkship wrote reflections on dilemmas that highlighted common struggles of becoming a doctor. Qualitative analysis was performed to determine common themes from the essays. The research team coded 173 reflections and identified themes and major domains. RESULTS: The first domain was Patient-Provider Conflict, including challenging patient (34%), difficult communication (25%), competing priorities between patients' interest and trainees need to learn (19%), and bias (13%). The second domain was Provider-Specific Issues, such as the "gray zone," in which there is not a clear standard of practice (29%), end-of-life care (14%), emotional struggle (6%), and fear of litigation (5%). The final domain was Systems Issues, such as cost of care (12%) and role of the emergency department (6%). CONCLUSIONS: The reflections point to a wide variety of challenges that students confront in practice that will contribute to how they develop into physicians.

Medical student perceptions of an initial collaborative immersion experience.

Recent reviews of interprofessional education (IPE) highlight the need for innovative curricula focused on longitudinal clinical learning. We describe the development and early outcomes of the initial clinical experience (ICE), a longitudinal practice-based course for first-year medical students. While IPE courses focus on student-to-student interaction, ICE focuses on introducing students to interprofessional collaboration. Students attend 14 sessions at one of 18 different clinical sites. They work directly with different health professionals from among 17 possible professions, including nurses, pharmacists, social workers, and respiratory, occupational, and physical therapists. Between 2015 and 2016, 167 students completed the course, and 81 completed the end-of-course evaluation. Students agreed or strongly agreed that ICE meaningfully contributed to their understanding of healthcare teams and different professional roles (86%), improved their understanding of healthcare systems (84%), improved their ability to communicate with healthcare professionals (61%), and improved their ability to work on interprofessional teams (65%). Select themes from narrative comments suggest that clinical immersion improves understanding of professional roles, helps students understand their own future roles in healthcare teams, and increases awareness of and respect for other professionals, with the potential to change future practice. ICE may be a template for other schools wishing to expand their current educational offerings, by engaging learners in more authentic, longitudinal clinical experiences with practicing healthcare professionals.

Efficient and Effective Use of Peer Teaching for Medical Student Simulation.

INTRODUCTION: Simulation is increasingly used in medical education, promoting active learning and retention; however, increasing use also requires considerable instructor resources. Simulation may provide a safe environment for students to teach each other, which many will need to do when they enter residency. Along with reinforcing learning and increasing retention, peer teaching could decrease instructor demands. Our objective was to determine the effectiveness of peer-taught simulation compared to physician-led simulation. We hypothesized that peer-taught simulation would lead to equivalent knowledge acquisition when compared to physician-taught sessions and would be viewed positively by participants. METHOD: This was a quasi-experimental study in an emergency medicine clerkship. The control group was faculty taught. In the peer-taught intervention group, students were assigned to teach one of the three simulation-based medical emergency cases. Each student was instructed to master their topic and teach it to their peers using the provided objectives and resource materials. The students were assigned to groups of three, with all three cases represented; students took turns leading their case. Three groups ran simultaneously. During the intervention sessions, one physician was present to monitor the accuracy of learning and to answer questions, while three physicians were required for the control groups. Outcomes compared pre-test and post-test knowledge and student reaction between control and intervention groups. RESULTS: Both methods led to equally improved knowledge; mean score for the post-test was 75% for both groups (p=0.6) and were viewed positively. Students in the intervention group agreed that peer-directed learning was an effective way to learn. However, students in the control group scored their simulation experience more favorably. CONCLUSION: In general, students' response to peer teaching was positive, students learned equally well, and found peer-taught sessions to be interactive and beneficial.

The Interprofessional Clinical Experience: Introduction to Interprofessional Education Through Early Immersion in Health Care Teams.

INTRODUCTION: The ability to collaborate as a member of interprofessional teams is essential for patient care and a core competency for students in health professions education. We developed a yearlong course, the Interprofessional Clinical Experience (ICE), to introduce first-year medical students to team-based aspects of the health care environment and provide them with a foundation upon which later experiences can grow. METHODS: The course uses experiential learning and critical reflection through reflective writing to orient students to working with care teams. Students receive assessments from faculty and various health care professionals. The course requires students to describe the roles and responsibilities of a variety of health care professionals, utilize effective communication with other health professionals on health care teams, demonstrate the ability to work on an interprofessional team, and examine their own and others' perspectives by engaging in self-directed learning and reflective practice. RESULTS: Annual course evaluations revealed that the majority of students agreed or strongly agreed that ICE contributed to their understanding of the health care team's roles and improved their ability to communicate with health care professionals, their understanding of health care systems, and their ability to work on an interprofessional team. The course also provides curricular content for the newly implemented Liaison Committee for Medical Education's accreditation requirement on interprofessional collaborative skills. DISCUSSION: The first implementation of this resource demonstrated that students met the educational objectives of the ICE and gained a better sense of the health care system and teams.

Essentials of PEM Fellowship Part 2: The Profession in Entrustable Professional Activities.

This article is the second in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine (PEM) fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article describes the development of PEM entrustable professional activities (EPAs) and the relationship of these EPAs with existing taxonomies of assessment and learning within PEM fellowship. It summarizes the field in concepts that can be taught and assessed, packaging the PEM subspecialty into EPAs.

Retention Curves for Pediatric and Neonatal Intubation Skills After Simulation-Based Training.

OBJECTIVES: We evaluated the retention of pediatric and neonatal intubation performance abilities of clinicians trained on a simulated or live tissue model at 3 intervals after initial training to assess competency degradation related to either training modality or retention interval. METHODS: We implemented a quasi-experimental design with purposive sampling to assess performance differences between 171 subjects randomly assigned to 1 of 3 intervals after initial training: 6 weeks, 18 weeks, or 52 weeks. Training followed the American Heart Association Pediatric Advanced Life Support and Neonatal Resuscitation Program protocols with hands-on practice using 1 of 2 models (live feline or simulated feline). Assessment data were captured using validated instruments and analyzed using analysis of variance with repeated measures (statistical significance set at P < 0.05). RESULTS: Cognitive retention scores decreased significantly (P = 0.000) from posttraining cognitive scores. There were no significant differences between posttraining and retention scores for pediatric and neonatal performances. Both affect and self-efficacy retention scores decreased significantly (P = 0.000) from posttraining scores at 18 and 52 weeks, but remained constant at 6 weeks. Retention scores for all dimensions showed a significant difference between subjects with varying amounts of experience performing pediatric and neonatal intubation, such that those with more experience scored higher those with less (P < 0.003). CONCLUSIONS: Retention performance outcomes decreased sufficiently from posttraining scores to suggest that training refreshment could serve to maintain posttraining competency in the ability to perform pediatric and neonatal intubation. Retraining intervals may be best aligned with provider experience levels. Future research focusing on the effect of variable interval refresher training on retention in pediatric and neonatal intubation is merited.

Reporting Achievement of Medical Student Milestones to Residency Program Directors: An Educational Handover.

PROBLEM: Competency-based education, including assessment of specialty-specific milestones, has become the dominant medical education paradigm; however, how to determine baseline competency of entering interns is unclear-as is to whom this responsibility falls. Medical schools should take responsibility for providing residency programs with accurate, competency-based assessments of their graduates. APPROACH: A University of Michigan ad hoc committee developed (spring 2013) a post-Match, milestone-based medical student performance evaluation for seven students matched into emergency medicine (EM) residencies. The committee determined EM milestone levels for each student based on assessments from the EM clerkship, end-of-third-year multistation standardized patient exam, EM boot camp elective, and other medical school data. OUTCOMES: In this feasibility study, the committee assessed nearly all 23 EM milestones for all seven graduates, shared these performance evaluations with the program director (PD) where each student matched, and subsequently surveyed the PDs regarding this pilot. Of the five responding PDs, none reported using the traditional medical student performance evaluation to customize training, four (80%) indicated that the proposed assessment provided novel information, and 100% answered that the assessment would be useful for all incoming trainees. NEXT STEPS: An EM milestone-based, post-Match assessment that uses existing assessment data is feasible and may be effective for communicating competency-based information about medical school graduates to receiving residency programs. Next steps include further aligning assessments with competencies, determining the benefit of such an assessment for other specialties, and articulating the national need for an effective educational handover tool between undergraduate and graduate medical education institutions.